[Time changes of mitral regurgitant jets: a 4th dimension for Doppler evaluation of the severity of mitral regurgitation]. / Variations temporelles des jets d'insuffisance mitral: une quatrième dimension pour évaluer la sévérité de la régurgitation au Doppler.

The quantitation of mitral regurgitation is based on measurement of the maximal jet area by colour flow mapping. Discrepancies have been reported with the possibility of significant temporal variations of jet size. The aim of this study was to determine whether evaluation could be improved by taking these variations into consideration. Three dimensional Doppler colour flow mapping by combining measurements of length, height and width of the jet in two orthogonal planes, in order to obtain a global index of regurgitation, was undertaken in 40 patients with angiographically documented mitral regurgitation classified in three degrees, mild, moderate and severe. Two-dimensional Doppler with colour M-mode was performed in each patient analysing early, mild and late systole. In the absence of significant temporal variation, assessment was based on measurement of maximal jet area alone (maximum global regurgitation index). When there were significant temporal variations, the index was calculated during each phase of systole and the values averaged to obtain a mean global regurgitation index. Temporal variations were observed in 14 of the 40 patients (35%), mainly in mild and moderate regurgitation. Significant differences were noted in the values of maximal (p < 0.01 to 0.001) and mean global regurgitation indices (p < 0.001 to 0.0001) between each degree of severity. A paired study demonstrated significant differences between the two indices in mild (p < 0.01) and moderate regurgitation (p < 0.05). Assessment of the severity of mitral regurgitation was satisfactory in 65% of cases using the maximal global regurgitation index with 14 overestimations, all in cases of mild and moderate regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Characteristics of jets in adult bicuspid aortic valve by color Doppler imaging]. / Caractéristiques des jets sur bicuspidie aortique de l'adulte en imagerie Doppler couleur.

Color flow mapping of 15 adults with bicuspid aortic valves confirmed angiographically and at surgery comprising 8 regurgitations and 7 stenoses was analysed, retrospectively in 12 cases. The object was to detect any special features of the jets of this congenital abnormality. The site of emergence of the jet at the aortic orifice and its direction in the left ventricle were studied in the long axis, short transaortic and left ventricular axes by sequential analysis. Two types of regurgitant jet were observed: eccentric anterior origin (5, Type I), eccentric posterior origin (3, Type II), extending towards the structure opposite to their origin in the left ventricular outflow tract. In cases of stenosis, the cross-sectional view of the jet had an almost transverse slit-like appearance extending from one side of the aortic orifice to the other or an anterior or posterior eccentric oval shape. The Type I cases and the slit-like anterior stenoses had fusion of the coronary cusps whilst the Type II and posterior slit-like stenoses had fusion of the right coronary and non-coronary cusps. This preliminary study suggests that bicuspid aortic valves are associated with jet characteristics related to the abnormal commissural axis which allows diagnosis and precision of the anatomic type in adults despite the presence of calcification.

[Chronology of maximal surface area and peak velocities of left heart valve flow jets using Doppler imaging. Clinical implications]. / Chronologies des aires maximales en imagerie doppler et du pic de vélocité en doppler continu des jets valvulaires gauches. Implications cliniques.

The aim of this study was to correlate the timing of the maximal surface area of the jet recorded by color flow Doppler and the peak velocities recorded by continuous mode Doppler with reference to the ECG R wave to determine whether standardisation of the chronologies of measurements was possible. A comparative paired study of these two parameters was undertaken in 44 subjects who had 55 left heart valvular lesions, all in sinus rhythm and, in cases of regurgitation, with pansystolic or pandiastolic regurgitant flow. The jets were examined in the inflow chambers of valvular insufficiency and at the origin of the jet in the short axis for stenotic lesions and aortic regurgitation, with planimetry of the cross sectional area in color Doppler. The correlation coefficient was 0.85 for aortic stenosis, 0.96 for mitral stenosis, 0.84 for aortic regurgitation but only 0.10 for mitral regurgitation. The mean values of the two chronologies were identical for stenotic lesions and did not differ significantly in regurgitation even at the mitral valve. However, the individual differences between the two chronologies exceeded 20 ms in 63% of aortic and 91% of mitral regurgitations. The maximal surface areas of the jets of 45% of aortic regurgitant and 91% of mitral regurgitant lesions were recorded between the onset of regurgitation and the peak jet velocity. The differences in chronology of the two parameters studied in cases of valvular regurgitation indicate the multifactorial nature of color flow jet imaging, probably associated with individual physiopathological variations.(ABSTRACT TRUNCATED AT 250 WORDS)

Respective timing of maximal color Doppler jet areas and of peak velocity of jets in left-sided valvular lesions: clinical implications.

Time intervals between the R wave of the electrocardiogram and maximal dimension of jet areas of color Doppler and the R wave of the electrocardiogram and peak velocity of valvular jets of continuous-wave Doppler were compared by use of paired and correlative studies for a group of 55 patients with a total of 71 left-sided lesions. Mean values of both time intervals, mean difference, and its standard error were equal to zero for stenoses. Time intervals of 71% for mitral stenosis and 52% for aortic stenosis did not differ by more than 0.01 second; correlation coefficients were 0.96 for mitral stenosis and 0.85 for aortic stenosis. For regurgitations, differences in mean values and a mean difference with a standard error were found but remained unsignificant. However, the percentage of differences in time intervals below or equal to 0.01 second decreased to 35 for aortic regurgitation and 13 for mitral regurgitation, which showed the widest 95% range of differences. Correlation coefficients were 0.84 for the aortic regurgitation and 0.33 for mitral regurgitation. Thus the close relationship of time intervals suggests that standardized timing of area measurements at peak velocity is feasible for stenoses and remains under consideration for aortic regurgitation. Timing of measurements should remain empiric for mitral regurgitation.

Quantification of left-sided valvular stenoses by color Doppler imaging of jets.

A new methodology for assessment of severity of stenosis employing color Doppler imaging and relying upon spatial and temporal studies of aortic and mitral stenotic jets is described. The spatial study consisted of the detection of the jet origin with respect to upstream and downstream trajectories in the long-axis view, with further identification of each of the three levels from characteristics single-gated Doppler flow recordings, when desired. For the temporal study, color images were gated in midsystole for aortic, and in early diastole for mitral, stenosis. The final step consisted of imaging the jet cross-sectional area in the short-axis view with planimetry. Measurements were compared with those obtained by the Gorlin formula. The procedure was feasible in 43 of 48 studied cases and the correlation between hemodynamic and color Doppler data was satisfactory for both valvular lesions. The best agreement between both methods was for severe stenoses, where the standard error of estimate was the lowest. For large areas the variance in measurements was wider and the correlation coefficient decreased, but this did not cause errors in recognition. This new method provides a convenient and rapid visualization of stenotic jets and is particularly recommended for assessment of severe stenoses, where accuracy was highest for all clinical conditions.

[Changes in mitral and tricuspid blood flow as a function of aging. Value of a combined study with Doppler echocardiography]. / Analyse des variations du flux mitral et tricuspidien en fonction de l'âge. Intérêt de l'étude couplée en échographie doppler.

The many factors, especially physiological, which influence mitral diastolic flow and the difficulties in interpretation motivated this study of age related changes of blood flow through the two atrioventricular orifices, taking tricuspid flow as the reference for evaluation of any change in mitral flow. Doppler echocardiographic studies were performed in 45 normal subjects who were divided into 3 groups according to age. The amplitude, duration and velocity time integrals (VTI) of the E and A waves were studied at the level of the valve rings and at the tips of the leaflets. Ventricular isovolumic relaxation periods were measured. The following age-related changes were observed at both atrioventricular valve orifices: increased amplitude and VTI of the A waves; decreased amplitude and VTI of the E waves, leading to a decrease or inversion of the ratios of the E/A wave amplitudes and VTI. No significant differences in the duration of the E and A waves were detected. An increase in the left ventricular isovolumic relaxation period was observed. Differences were also recorded according to the site of the Doppler sample volume: increased amplitude, duration and VTI of the E and A waves when the flow was recorded at the tips of the valve leaflets. This underlines the value of using the E wave VTI/total VTI ratio which was unaffected by the sample volume position. An age-related decrease in this ratio was demonstrated at both atrioventricular valve orifices.(ABSTRACT TRUNCATED AT 250 WORDS)

[A new quantitative method for quantifying left heart jets by Doppler color imaging]. / Nouvelle approche méthodologique quantitative des jets valvulaires gauches en imagerie Doppler couleur.

Quantification of valvular lesions by Color Doppler is based on jet measurements. The aim of this new method is to reduce some of the errors in these measurements: uncertainty in delimiting the colored areas of the jets; spontaneous beat-to-beat variations of the jets entailing interpretative difficulties. The first step was to determine the correlations between the colored areas and previously established single-gated Doppler criteria, retaining spectral criteria to define the borders of the jets, so overcoming some of the limitations of color Doppler. The association of these methods resulted in better discrimination between grades and a better correlation in 45 angiographically controlled mitral and aortic regurgitations than with color Doppler alone. In stenotic lesions, spectral criteria from single-gated associated exploration enabled localisation of the level for planimetry of the section of the jet at its origin visualised by color Doppler. Satisfactory correlations were obtained with the Gorlin surface area in a group of 43 patients with mitral and aortic stenosis. A coefficient of variation of 13 to 14 per cent was found with planimetry of the regurgitant jet in the upstream cardiac chamber. Uni-dimensional measurement decreased this variation to 6 to 11 per cent in the same patients. The largest decrease in variability (6 to 8 per cent) was observed in stenotic and regurgitant lesions with planimetry of the section of jet at its origin performed in held mid-expiration and so this would appear to be the best method. The guide lines and technological improvement associated with the physiopathological information provided by color Doppler should refine the quantification of valvular heart lesions.

Doppler flow mapping and its comparison with the continuity equation method for quantifying aortic stenosis.

The flow-mapping technique, which detects and planimeters the area of systolic flow at the site of the aortic orifice, was applied to 59 patients with a stenosed aortic valve, all of whom underwent cardiac catheterization. The success rate was 93%. The correlation coefficient between the values of valvular areas obtained by Doppler and those yielded by the Gorlin formula was r = 0.93 (SEE = 0.12 cm2). The continuity equation procedure, with the use of the velocity-time integrals, was applied sequentially to 20 of the above mentioned patients. The success rate was 85%. The valvular areas obtained in these patients by the Gorlin formula correlated well with those obtained with flow mapping (r = 0.90, SEE = 0.14, standard deviation of the difference = 0.13 cm2), as well as with those yielded by the continuity equation procedure (r = 0.86, SEE = 0.17 cm2, standard deviation of the difference = 0.16 cm2). Furthermore, the data from both ultrasonic methods were satisfactorily cross-correlated (r = 0.92, SEE = 0.12 cm2). It is noteworthy that the values of aortic valvular area obtained by Doppler were slightly larger than those found using either the continuity equation procedure or the Gorlin formula. The authors conclude that the flow-mapping technique represents a reliable method for quantifying stenotic aortic valvular area and correlates well with the continuity equation procedure. It is therefore suggested that, whenever possible, both techniques should be used sequentially as a valuable and practical cross-checking policy.

[Clinical value of the detection of diastolic mitral regurgitation by pulsed Doppler]. / Intérêt clinique de la détection par Doppler pulsé des régurgitations mitrales diastoliques.

The reliability of pulsed Doppler echocardiography for the detection of mitral diastolic regurgitation was evaluated in 21 patients with severe aortic insufficiency and/or cardiomyopathy. Among these patients, 17 had sinus rhythm with a normal PR interval, while 4 had atrial fibrillation with short or normally lasting diastoles. Detection was negative in 10 cases (group A) and positive in the remaining 11 cases (group B). In all patients the data supplied by Doppler echocardiography were confirmed by angiography (100% sensitivity and specificity). A comparative study of right heart and left heart pressures in the two groups showed that group B patients had a special pressure profile, the most significant feature of which was an increase in pulmonary arterial and capillary pressures (p less than 0.01 and p less than 0.001 respectively). The diagnostic reliability of mitral valve diastolic regurgitation as to the presence of an abnormal mean pulmonary pressure was: sensitivity 80%, specificity 73%. Right heart pressures were either normal or very slightly elevated in group A patients. It is concluded that the presence of mitral diastolic regurgitation in patients with the pathology described indicates an unfavourable prognosis. This should be taken into account and lead to a systematic of mitral flow in these patients.

Application of Doppler flow mapping in assessing the severity of mitral stenosis.

The purpose of the flow mapping procedure is to pick up flow signals related to jets at the site of lesions, in order to delineate the cross-section of the jets. The pulsed Doppler procedure was applied to a group of 33 consecutive patients with mitral stenosis confirmed invasively in all cases and by surgery in 15 cases. The examination involved the recording of flow signals at the distal edge of the mitral oriface investigated in the short-axis view. Doppler criteria for required flow signals were the presence of a high-pitched tone and of a laminar spectrum, occurring at a definite timing in early to mid-diastole, i.e. at the period of the maximal atrioventricular pressure gradient. Planimetry of the flow area was performed and correlated with haemodynamic data using the Gorlin formula. The procedure was applicable in 32/33 patients. The correlation coefficient was 0.94, standard error of estimate 0.13 cm2, P less than 0.001. The mean difference between invasive and non-invasive measurements was -0.04 +/- 0.14 cm2 and the standard error of the mean 0.03 cm2. This new application of flow mapping provided reliable information for the later surgical procedure. It should benefit in future from improvements in spatial resolution and in signal to noise ratio.

A new non-invasive estimation of the stenotic aortic valve area by pulsed Doppler mapping.

A new pulsed Doppler mapping technique has been used to measure the severity of aortic valve stenosis. The Doppler examination was performed at the site of the aortic orifice in the parasternal short axis echocardiographic view and the method was based on the detection of the area of systolic flow through the stenotic orifice. This area was derived by planimetry and the measurements obtained by the Doppler method were compared with the aortic valve area calculated at catheterisation according to the Gorlin formula. The method was applicable in 41 of the 44 patients studied. The Doppler data were consistent with the haemodynamic measurements even in patients with decreased cardiac index. It is concluded that this new application of the flow mapping procedure is reliable and is easily applied to adult patients with a wide range of clinical conditions.

[Doppler technics in the study of prosthetic valves]. / Contribution des techniques Doppler à l'étude des prothèses valvulaires.

The authors studied a group of 120 patients and a total of 137 valvular prostheses by ultrasonic pulsed Doppler (3 MHz). Fifty three of these prostheses were also investigated with continuous wave Doppler. Clinical, phonocardiographic and echocardiographic examination revealed 99 normal and 38 abnormal prostheses, the latter group comprising 42 dysfunctions (9 obstructions and 33 regurgitations), all confirmed by invasive studies. The lesions were graded into 3 degrees of severity. The methods used were the recording of velocity signals and two- and three-dimensional mapping in the pulsed Doppler mode, and the calculation of the haemodynamic parameters derived from measurements of blood velocity in the continuous wave mode. Pulsed Doppler correctly diagnosed 92 out of the 99 normal prostheses. The maximum systolic pressure gradient in aortic valve prostheses was 16 +/- 6 mmHg; the average early diastolic pressure gradient of the mitral valve prostheses was 10.01 +/- 3.34 mmHg, with a mean diastolic gradient of 4.52 +/- 0.71 mmHg and a mean pressure half time of 0.09 +/- 0.02 sec giving an average valve surface area of 2.45 +/- 0.57 cm2. The sensitivity and specificity of the diagnosis of valve dysfunction were 95 and 92 per cent respectively with a satisfactory evaluation of the degree of severity in 88 per cent of cases. In the 3 mitral valve prostheses with obstruction, significant abnormalities of pressure half time and value surface area were detected.(ABSTRACT TRUNCATED AT 250 WORDS)

Applications of pulsed Doppler flow mapping to left sided cardiac valvular lesions.

The flow mapping procedure has been developed in parallel to the standard pulsed Doppler procedure. It has a different purpose--picking up flow signals at the site of lesions rather than calibrating velocities--and has its own methodology, developed within the last six years. On the basis of invasive correlations performed in 267 cases of valvular heart disease, we review the three-fold purpose of the flow mapping technique: diagnosing lesions, relying on the presence of flow anomalies; assessing their severity, relying on the spatial spreading of these flow signals; and identifying the site of the lesion, which is a specific advantage, relying on the anatomical location of these flow signals and/or on the direction of the jets. For example, using this technique, it is now possible to easily differentiate a cusp tear from a leak of a bioprosthesis, to measure the size of the leaks, and to reconstruct the image of aortic or mitral stenotic areas. These optimal results are only obtained using an appropriate methodology which mainly includes a) the selection of adequate two-dimensional short axis planes in order to explore the diseased valve in its entirety, because of frequent assymetrical orifices, and to pick up the jets at their starting point, b) measurements of the abnormal areas, c) when jets are studied, a three dimensional approach is required in order to cope with the three dimensional nature of the jet and to make available the calculation of three dimensional indices of severity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of pulsed and continuous Doppler techniques for the evaluation of left ventricular stenoses]. / Comparaison des techniques Doppler pulsé et continu pour l'évaluation des sténoses valvulaires gauches.

The authors compared the data obtained with pulsed (pulsed Doppler-Scanner 3 MHz) and continuous wava Doppler (2.5 MHz), with that obtained by catheterisation in the evaluation of severity of valvular stenoses. The study material comprised 10 healthy subjects and 45 patients with mitral (21) and aortic (24 cases) stenosis, all of whom underwent catheterisation. Stenosis was graded in 3 degrees of increasing severity based on the catheter data. In addition, we studied the correlations between the transvalvular mitral and aortic pressure gradients, calculated by continuous Doppler and catheterisation, and the time of half decrease of flow measured by continuous Doppler and the mitral surface area calculated by catheterisation. No abnormality Was noted in the healthy patients. The jet of the aortic stenosis could not be recorded by continuous Doppler in 8 cases and aortic flow could not be recorded in 1 case with pulsed Doppler. The linear correlation with continuous Doppler was 0.96 (aortic transvalvular gradient for the 16 jets obtained), 0.81 (mitral transvalvular gradient), and 0.80 (time of half decrease of flow and mitral surface area calculated with catheterisation). The comparative study of the degree of severity gives the following percentages of success: mitral stenosis, 85% (pulsed Doppler) vs 71% (continuous Doppler) for mitral stenoses; aortic stenoses 83% (pulsed Doppler) vs 58% (continuous Doppler). In the 16 cases where the aortic jet was recorded properly this percentage was 87% (continuous Doppler) vs 81% (pulsed Doppler). In conclusion, the advantage of continuous Doppler over pulsed Doppler is that it provides quantitative parameters in correlation with catheter data. It is mainly used for evaluating recording the jet should significantly suggest that in elderly patients a systematic right parasternal approach in the jet should significantly reduce the failure rate observed in this study. It is of more limited value in mitral stenoses where pulsed Doppler gives more detailed information about the flow through the mitral valve. This, and the fact that pulsed Doppler can also be used for assession of aortic stenoses, illustrate the complementary nature of the two technique which should always be used together.

Quantification of left to right shunt in atrial septal defect using systolic time intervals derived from pulsed Doppler velocimetry.

Systolic time intervals derived from Doppler velocimetry measurements were used instead of direct pulmonary to systemic flow ratio measurements in adults with atrial septal defect to quantify left to right atrial shunts. Thirteen normal subjects and 25 patients with uncomplicated atrial septal defect confirmed by cardiac catheterisation were studied. The pulmonary to systemic flow ratio (Qp:Qs) expressing the shunt size was determined by the Fick method; in normal subjects the Qp:Qs ratio was assumed to be equal to 1.0. The pulsed Doppler analogue velocity recording of flow in the pulmonary artery and the ascending aorta was taken as indicating the ejection time of each ventricle and the Q wave of the electrocardiogram as indicating the onset of systole. From these measurements the ratios of the pre-ejection periods to the ejection times (haemodynamic ratio) were calculated for each ventricle and the ratios of each variable (pre-ejection period, ejection time, and haemodynamic ratio) were calculated for both ventricles. Significant differences were found between the normal subjects and the patients with atrial septal defect for all these ratios. When the Doppler findings and the Fick measurements of Qp:Qs were compared the best linear correlation coefficient was for the left to right haemodynamic ratio. It is concluded that the use of a ratio involving several variables, such as the pre-ejection period and the ejection time for both ventricles, improves the reliability of this method, which appears to be applicable in adults.

Calculation of pulsed Doppler left ventricular outflow tract regurgitant index for grading the severity of aortic regurgitation.

Measurement of the spatial extent of the regurgitant jet was performed in the left ventricular outflow tract (LVOT) with a 3 MHz two-dimensional echo-pulsed Doppler device, in order to assess the severity of aortic regurgitation on a quantitative basis. The procedure included: detection of diastolic disturbances in the LVOT and mapping of these disturbances in the LVOT. Length (L) and height (H) were measured with calculation of the product (L X H) in the long-axis view and width (W) in the short-axis view with calculation of the LVOT regurgitant index (LVOTRI) as follows: ([L X H] X W). Twelve normal subjects and a group of 83 patients, including 40 patients with aortic regurgitation proved by aortography, were investigated with this procedure. Diagnostic reliability ranged between 90% for specificity and 95% for sensitivity. Correlations between the grading provided by the LVOTRI and those provided by aortography on a three-grade scale showed a correlation coefficient between 0.67 (linear model, p less than 0.01) and 0.80 (exponential model), because of the high values of the index in cases of severe regurgitation. Reliability of the LVOT investigation in aortic regurgitation requires the use of information from two combined scan planes and quantitative rather than qualitative data. Main limitations of the procedure are due to the presence of associated mitral lesions.

Localization of the origin of systolic clicks using echo-pulsed Doppler technique.

Echo-pulsed doppler (EPD) studies were performed in 2 surgically controlled patients with systolic clicks. The recorded blood samples documented the click to be originated in the right atrium, at the site of the prolapsed anterior tricuspid leaflet in 1 case of heroin-induced tricuspid acute endocarditis. In the second patient suffering from aortic valve disease, an ejection click was recorded, and could be demonstrated by using EPD, to originate from the aortic leaflet at its time of maximal excursion. EPD apears to be a safe, noninvasive method to solve the problem of the origin of systolic clicks.